<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:52:42 AM


Document Has Been Signed on 08/22/2023 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ARMANDO RODRIGUEZFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 115DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator - Aimee Jo MattsonTIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced case management incident inspection visit. Community Care Licensing received an incident report indicating that resident #1 (R1) Absence without Leave (AWOL) occurred on June 21, 2023. LPA met with administrator and explained purpose of the visit.

LPA interviewed the Administrator regarding the absence of R1.
R1 left facility on June 21, 2023 at unknown time and is unable to know how to return to facility. R1 was found near hospital by good samaritan after he was observed walking, but confused. Samaritan called police and they were able to verify his identification. R1's son was called and he returned R1 to facility. Arrival time was at approximately 9:15 PM on June 21, 2023. The staff on duty had no knowledge of the (AWOL) until police contacted the Administrator. Upon LPA review of the most recent Physician Report (LIC 602) dated 5/22/2023, it indicates that R1 is not able to leave the facility unassisted. R1 moved out of facility on June 22, 2023 due to needing a higher level of care.

LPA received the following document for R1: LIC 602 (Medical Assessment).

Per California Code of Regulations California Health and Safety Code - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. If the following cited deficiency is not corrected by the noted due date; additional civil penalties may be assessed.
Immediate Civil Penalty of $500.00 cited.

An exit interview was conducted with administrator. A copy of this report, LIC 811 (Confidential Names), and appeal rights were left at the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/22/2023 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 557005532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2023
Section Cited
HSC
1569.312(d)

1
2
3
4
5
6
7
HSC - 1569.312(d) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee agrees to conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 8/23/203 via email to LPA Kim Viarella. Proof of staff training for the cited section will be completed and asignature sheet of all staff who attended will be submitted to LPA Kim Viarella after training is finished.
8
9
10
11
12
13
14
Based on incident report, the facility did not comply with section cited above in 1569.312(d). R1 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.
8
9
10
11
12
13
14
Immediate civil penalty of $500.00 cited for health and safety deficiency.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2